Does Medicaid cover Enbrel?

In this article:

• How much does Enbrel cost?
• Does Medicaid cover Enbrel?
• Factors influencing Medicaid coverage of Enbrel
• How to get Enbrel with Medicaid
• Cost of Enbrel with Medicaid
• Ways to get discounts on Enbrel without Medicaid

In this article

• How much does Enbrel cost?
• Does Medicaid cover Enbrel?
• Factors influencing Medicaid coverage of Enbrel
• How to get Enbrel with Medicaid
• Cost of Enbrel with Medicaid
• Ways to get discounts on Enbrel without Medicaid

Enbrel (etanercept) is a brand-name prescription medication for treating autoimmune diseases such as rheumatoid arthritis, psoriasis, and ankylosing spondylitis. It belongs to a class of medications called tumor necrosis factor (TNF) inhibitors. A TNF inhibitor is a protein the white blood cells produce in the body that plays a role in inflammatory processes. Enbrel is given as a self-injection, and it works by blocking proteins in your body that cause pain and swelling.

Medicaid is a program funded by states and the federal government that provides health insurance to low-income individuals and families. While the coverage and eligibility criteria for Medicaid can vary from state to state, the program ensures that those most in need have access to essential healthcare services, including prescription medications like Enbrel.

How much does Enbrel cost?

Without insurance or Medicaid, Enbrel can be expensive. On average, a 30-day supply of Enbrel costs $8,658 without insurance or discounts, which can be a significant barrier for many patients. 

Several factors can influence the price:

• Dosage: The diseases being treated, the dosage, and the frequency of injections can impact the overall monthly cost.
• Pharmacy: The price of Enbrel can vary between pharmacies. Pharmacists can help you compare prices at different locations.
• Location: Costs can also differ based on geographic location. 

Does Medicaid cover Enbrel?

The answer is not a simple yes or no. In most cases, Enbrel is covered by Medicaid, but certain factors must be considered when determining coverage. Different Medicaid plans have unique drug lists, or formularies, which are lists of medicines that they will pay for. Enbrel may be included in this formulary, but it’s essential to confirm this with your state’s Medicaid program or your unique Medicaid plan.

Some states may cover Enbrel, while others may not. In states where Medicaid includes Enbrel in its preferred drug list, there may still be specific criteria you must satisfy before your healthcare provider can prescribe it. 

For example, Texas Medicaid may cover Enbrel for conditions like rheumatoid arthritis if it meets specific criteria and prior authorizations are obtained. The approval process may involve submitting detailed information about your medical condition and previous treatments.

If you have both Medicare and Medicaid, you are considered dually eligible, meaning you may be able to use Medicaid to pay for certain things that Medicare won’t, though this is not necessarily a guarantee.

RELATED: Does Medicare cover Enbrel?

Factors influencing Medicaid coverage of Enbrel

If Medicaid covers Enbrel in your state, there may be specific requirements you must meet. These may include:

• A confirmed diagnosis: Your healthcare provider must diagnose you with an autoimmune condition that Enbrel is used to treat
• Proof of medical necessity: Your healthcare provider must demonstrate that Enbrel is necessary for your specific condition and that other treatments are ineffective. This process, known as step therapy, involves trying less expensive medications before trying Enbrel.
• Prior authorization: If your state’s Medicaid agency requires prior authorization for Enbrel, your healthcare provider must get approval from Medicaid before the prescription may be filled at the point of sale. The process typically involves submitting detailed information about your condition and why Enbrel is necessary.
• Your income level: Medicaid coverage can also depend on your income level. Some states have specific income thresholds determining eligibility for certain benefits, including prescription medications like Enbrel.

To determine whether Medicaid covers Enbrel in your state:

• Check your state’s Medicaid website. Each state has a Medicaid website where they can find information about covered medications and services. This site can provide specific details about Enbrel coverage in your state.
• Call your local Medicaid office. Contacting your local Medicaid office can provide direct information about Enbrel coverage. They can explain the process for obtaining coverage and any additional requirements.
• If your Medicaid plan is managed instead of fee-for-service, check your managed Medicaid plan’s formulary. This will let you know not only whether it covers Enbrel but also how much of a copay you’ll be responsible for at the pharmacy.

How to get Enbrel with Medicaid

If you want to obtain Enbrel with Medicaid coverage, follow these steps:

1. Discuss your condition and treatment options with your healthcare provider. If Enbrel is deemed appropriate, they will write a prescription.
2. Allow time for prior authorization. Don’t assume you’ll be able to start taking Enbrel right away. Filling your Enbrel prescription can take more time than other medications if Medicaid requires prior authorization. Your healthcare provider may first have to submit the necessary forms and information to Medicaid for approval, proving that Enbrel is necessary for your specific condition. 
3. Fill the prescription: Once Medicaid approves the prior authorization, you can take the prescription to your pharmacy. 

Cost of Enbrel with Medicaid

Medicaid may cover the complete cost of Enbrel, or it may require you to pay a copay. Ultimately, it depends on your Medicaid plan. You may have out-of-pocket expenses such as:

• Copayments: Some plans require a copayment for each prescription. The copay amount may depend on whether your state considers Enbrel a preferred or nonpreferred drug. You’ll pay a copay of $4.95 or less per month for preferred drugs. For nonpreferred drugs, you’ll pay $9.85 or less if your household income is no more than 150% of the federal poverty level. If your income is higher, you may be required to pay 20% of what Medicaid pays for Enbrel.
• Coinsurance: Sometimes, you pay a percentage of the medication cost, known as coinsurance. For example, you might pay 10% of the medication’s price.
• Monthly premiums: Depending on your income and Medicaid plan, you might have to pay a monthly premium for Medicaid coverage. The amount can vary based on your state and specific Medicaid program.
• Deductible: Some plans have a deductible, which is an amount you have to pay before coverage begins. 

To understand what you’ll pay, check your state Medicaid preferred drug list.

Ways to get discounts on Enbrel without Medicaid

If you don’t have Medicaid or if your state doesn’t cover Enbrel, you can still find ways to save on the medication:

• SingleCare prescription discount card: The SingleCare discount card offers digital coupons that can lower the cost of Enbrel at many pharmacies. For example, with a SingleCare coupon for Enbrel, you could pay $6,788 instead of $8,658 for four syringes, a one-month supply.  
• Manufacturer coupons: Check the manufacturer’s website for Enbrel to see if it offers any coupons or discount programs. These programs may provide significant savings on the medication.
• Enbrel patient assistance: The Amgen Safety Net Foundation offers a patient assistance program that provides free medication, including Enbrel, to eligible patients who can prove that they are ineligible for Medicaid and meet certain income requirements.
• Generic alternatives: While Enbrel itself doesn’t have a generic version yet, your healthcare provider might know of other similar Enbrel alternatives that are more affordable.

To find out whether Medicaid will cover your Enbrel prescription, check with your local Medicaid office for the most up-to-date information. By being informed and proactive, individuals can navigate the complexities of Medicaid coverage for Enbrel and access the treatment they need for their autoimmune condition.